Name
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First Name
Last Name
Occupation
Email
*
Phone
*
Country
(###)
###
####
Mailing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What is your preferred method of communication?
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What is your birthday?
*
MM
DD
YYYY
What are your reasons for seeking Kayakalpa?
*
Please summarize any significant medical history from the past five years.
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Please note any surgeries or operations, chronic ailments, or untreated conditions.
Do you have any allergies, sensitivities or dietary restrictions?
*
Please list and prescription medications, vitamin, minerals or supplements that you currently take or have taken in the past six months.
*
I understand that Kayakalpa is a technique to promote optimal health and vitality and is not intended to diagnose, prevent, or treat any medical condition
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By checking this box I acknowledge that I have read and understand the proceeding statement.
Todays Date
*
MM
DD
YYYY
Stamina & Endurance
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Frame
*
Skin
*
Hair
*
Eyes
*
Nails
*
Urine
*
Appetite
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Stool Elimination
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Perspiration
*
Sex Drive
*
Physical Activity
*
Pulse / Heart Rate
*
Measure your pulse in your wrist or in your neck using your first two fingers.
Sleep
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Dreams
*
Memory
*
Mental State
*
Emotional State
*
Methods of Expression
*
Speech
*
List any cravings or addictions that you might have.
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Taste
*
Which tastes appeal to you the most? Sweet, salty, sour, bitter, astringent, pungent (astringent meaning drawing moisture and pungent meaning spicy).
Lifestyle
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Describe your routines, habits, hobbies and diet.
Menstruation Flow
What age did you get your first period?
If you are postmenopausal please write your age at your last period
Was your cycle regular when you first started menstruating?
Please provide details regarding your current cycle.
Is your cycle regular? Is it delayed or early? Is the flow normal, excessive, or small? Do you experience body ache, backache, headache or water retention during your cycle?
Have you had any abortions or miscarriages?
If you have children, please briefly describe the delivery.
Please note any issues or abnormalities with the pregnancy, delivery, or postpartum experience.
Does your menstrual cycle affect your emotional state? If so, please note how.
Please describe if you have experienced any changes in your menstrual cycle as a result of an illness or chronic condition.
By typing my full legal name, I acknowledge and understand the statement below:
*
The undersigned, being at least 18 years old (hereinafter referred to collectively as “I”), attest that I have read, understood and signed the following release.
No refunds are permitted for any treatments, retreats, or deposits. Credit may be applied in certain circumstances if the client wishes to modify their treatment schedule within fourteen (14) days of the scheduled treatment.
I understand that the Kayakalpa Session provided by the Kayakalpa Alchemy Foundation is intended to promote general well being and in no way intended to diagnose, prevent or cure any illness or injury.
IN CONSIDERATION OF THE USE OF THE POOL , GROUNDS AND FACILITIES AT KAYAKALPA ALCHEMY FOUNDATION,4901 WARM SPRINGS RD GLEN ELLEN CA 95442 I HEREBY ASSUME ALL RISKS AND HOLD HARMLESS, RELEASE, INDEMNIFY AND DEFEND THE CEO, DIRECTOR AND OFFICERS OF KAYAKALPA ALCHEMY FOUNDATION, AND ITS SUBSIDIARIES AND AFFILIATES, THEIR RESPECTIVE OFFICERS, DIRECTORS, AGENTS, SERVANTS AND EMPLOYEES (HEREINAFTER KAYAKALPA) OF AND FROM ANY LIABILITY, CLAIMS, DEMANDS, ACTIONS AND CAUSES OF ACTION WHATSOEVER WHICH MAY BE ASSOCIATED WITH AND/OR RESULT FROM MY INVOLVEMENT IN SUCH AN ACTIVITY AND/OR ARISING OUT OF OR RELATING TO ANY TREATMENT OBTAINED BY ME AT THE KAYAKALPA SAMADHI RETREAT OR RELATED TO ANY LOSS, DAMAGE OR INJURY, INCLUDING DEATH, THAT MAY BE SUSTAINED BY ME WHILE PARTICIPATING IN THE ACTIVITY AND/OR RECEIVING A SPA TREATMENT OR MASSAGE, INCLUDING BUT NOT LIMITED TO, THOSE INJURIES AND DAMAGES CAUSED BY NEGLIGENCE, RECKLESSNESS OR RECKLESS BEHAVIOR, BREACH OF WARRANTY, AND/OR ANY OTHER IMPROPER CONDUCT, EXPRESS OR IMPLIED, ON THE PART OF KAYAKALPA.
The general benefits of Kayakalpa and the session procedures have been explained to me. I understand that Kayakalpa is not a substitute for medical treatment or medications, I am aware that the Kayakalpa practitioner does not diagnose illness or disease, and does not prescribe medications. I understand that this Release shall be construed according to and governed by the laws of the State of California.
I understand that the use of swimming pools, hot tubs, and steam rooms may be included in my Kayakalpa session and visit. If I choose to use the above-mentioned facilities, I understand that their use represents potentially HAZARDOUS activities (hereinafter “Activity”). I hereby agree to freely and expressly ASSUME and accept ANY and ALL RISKS OF INJURY OR DEATH to me while participating in the Activity. Further, I voluntarily elect to participate in the Activity. I recognize that injuries are a common and ordinary consequence of the Activity.
I agree and understand that:
• Kayakalpa does not provide a lifeguard for the pools I SWIM AT MY OWN RISK.
• I assume the risk for drowning, slipping, and falling in and around the pool facilities.
• Diving is not permitted in the pool at Kayakalpa. I risk serious injury or death by diving into the pool.
• Kayakalpa reserves the right to close pools at any time for any reason without prior notification.
• It is my responsibility to be aware of any sensitivity I may have to pool sanitizing chemicals or additives. Kayakalpa is not responsible for any allergic reaction to pool conditions.
By execution of this release, Kayakalpa shall be indemnified by me for any injury to other person(s) or property which I may cause as a result of engaging in this Activity or in use of the Spa or in receiving services and/or treatments from the personnel at Kayakalpa. I contractually agree that any and all disputes between myself and Kayakalpa Foundation arising from my participation in the Kayakalpa or in the use of the pool or in receiving services and/or treatments from the personnel including any claims for personal injury and/or death, will be governed by the laws of the State of California and exclusive jurisdiction thereof will be in the state court residing in Sonoma County where the alleged tort occurred or the federal courts of the State of California.
This Release shall be binding to the fullest extent permitted by law. This Release shall be binding upon my assignees, subrogors, distributees, heirs, next-of-kin, executors, personal representatives, and administrators and may be pled by as a complete bar and defense against any claim, demand, action or causes of action brought by me or on my behalf.
I have carefully read the foregoing warning and liability release, understand its contents and sign it with full knowledge of its significance.
